86-146 - Laserfiche WebLink

Home Browse Search

' APPLICATION FOR PERMIT r r SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T Ofd AVE„ STOCKTON, CA 'Telephone (209) 466-Mll PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ,:,'(Complete in Triplicate) I Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and'the Rules and Regulations of the San Joaquin Local Health District. Job Address /C.� City.511-;il�, Lot Size PM Owner's Name Address 11E: Phone 4qqR Contractor JEC",b • jZh2d-b—Address_a 0 V. L/4.1-1AA) Ad License .No. Phone, 971 TYPE OF WEL-L•1-PUMP:-= = NEW-WELL-'❑WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE 1 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL _PROBLEM A•RErA CONSTRUCTION SPECIFICATIONS O Industrial ❑ Oben Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy ; Type of Casing 1 Specifications LlPublic [IOther C1Delta Depth of Grout Sal Type of Grout ❑ Irrigation --JApprox. Depth ❑ Eastern _ Surface Seal Installed by Repair Work bone ❑ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material ;top 501 I Depth Filler Material {Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑J(No septic system permitted if public sewer is I ' 1 available within 200 feet.] Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms_ 1 Character of soil to a depthlof 3-feet - Water table depth w SEPTIC TANK ❑ Type/Mfg al� Capacity,1 41 No. Compartments t E 7 w=� ,. t PKG. TREATMENT PLT. ❑ -XrsMethod of Drs po_sal Distance to nearest: Well Foundation ""+Property Line ► LEACHING LINE ❑ No. & Length of lines �? 3 � Total length/size 6 FILTER BED ' O Distance to nearest: Welt ` Founh ion iProperty Line i ., r • SEEPAGE PITS � LlDepth fD Size 2 +KIt Number SUMPS W-11&st1nce to nearest: WellJ'+Foundation �10 z Property Line t DISPOSAL PONDS ❑ i I Ztlfq r I hereby certify that I have prepared this application and that the work'i 411 be done in accordance with San Joaquin county ordinances, state laws, and ' r rules and regulations of the San^Joaquin Local Health District. r Home owner or licensed agent'ssignature certifies'the4following: "I certify that in the performance of the work for which this permit is issued,' I shall not employ any person in such.manner as to become subject to-workman's compensation laws of California."Contractor's hiring or sub-contracting signature Compecertifies the following:"I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's nsa—tion laws of California." �+ The applicant must call for all required inspections. Co plate drawing on reverse side. f€' Signed �} Title: I Date: -" � FOR DEPARTMENT USE ONLY a Application Accepted by Date — Area Pifor Grout Inspection by Date's P � Final Inspection by date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies,to: Environmental Health:Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 k FEE AMOUNT DUE AMOUNT-REMITTED INFO •.,^, �!GASH] RECEIVED BY DATE PERMIT NO. ` + EN 13-24(REV.1 i H 5f EH 14-28